Polypathological Patients Research Articles

Metodología de conciliación del tratamiento farmacológico en pacientes pluripatológicos

ObjectiveTo carry out a bibliographic review in order to identify the different methodologies used along the reconciliation process of drug therapy applicable to polypathological patients. DesignWe performed a literature review.Data sources The bibliographic review (February 2012) included the following databases: Pubmed, EMBASE, CINAHL, PsycINFO and Spanish Medical Index (IME). The different methodologies, identified on those databases, to measure the conciliation process in polypathological patients, or otherwise elderly patients or polypharmacy, were studied.Study selection Two hundred and seventy three articles were retrieved, of which 25 were selected.Data extraction Specifically: the level of care, the sources of information, the use of registration forms, the established time, the medical professional in charge and the registered variables such as errors of reconciliation. ResultsMost of studies selected when the patient was admitted into the hospital and after the hospital discharge of the patient. The main sources of information to be highlighted are: the interview and the medical history of the patient. An established time is not explicitly stated on most of them, nor the registration form is used. The main professional in charge is the clinical pharmacologist. Apart from the home medication, the habits of self-medication and phytotherapy are also identified. The common errors of reconciliation vary from the omission of drugs to different forms of interaction with other medicinal products (drugs interactions). ConclusionsThere is a large heterogeneity of methodologies used for reconciliation. There is not any work done on the specific figure of the polypathological patient, which precisely requires a standardized methodology due to its complexity and its susceptibility to errors of reconciliation.

Differential characteristics in polypathological inpatients in internal medicine departments and acute geriatric units: The PLUPAR study

AimTo determine whether there are any differences between polypathological patients attended in Internal Medicine departments and acute Geriatric units. MethodsA cross-sectional multicenter study was performed. Polypathological patients admitted to an internal medicine or geriatrics department and attended by investigators consecutively between March 1 and June 30, 2011 were included. Data of age, sex, living in a nursing residence or at home, diagnostic category, use of chronic medication, Charlson, Barthel and Lawton–Brody indexes, Pfeiffer questionnaire, delirium during last admission, need of a caregiver, and having a caregiver were gathered. The need of a caregiver was defined when the Barthel index was<60 or Pfeiffer questionnaire≥3 errors. Results471 polypathological patients, 337 from internal medicine and 144 from geriatrics units were included. Geriatrics inpatients were older and more frequently female. Cardiac (62.1% vs 49.6%; p=.01), digestive (8.3% vs 3.0%; p=.04) and oncohematological diseases (30.2% vs 18.8%; p=.01) were more frequent in patients of internal medicine units and neurological (66.2% vs 40.2%; p<.001) and locomotive ones (39.1% vs 20.4%; p<.001) in geriatrics inpatients. Charlson index was higher for internal medicine inpatients [4.0(2.1) vs 3.5(2.1); p=.04). Patients attended in geriatrics scored higher in Pfeiffer questionnaire [5.5(3.7) vs 3.8(3.3); p<.001], and lower in Barthel [38.8(32.5) vs 61.2(34.3); p=.001] and Lawton–Brody indexes [0.9(1.6) vs 3.0(2.9); p<.001], and more frequently needed a caregiver (87.8% vs 53.6%; p<.001) and had it. ConclusionsThere are differences in disease profile and functional and cognitive situation between polypathological patients of internal medicine and geriatrics departments.

Patient‐Centered Care for Older Adults with Multiple Chronic Conditions: These are the Polypathological Patients!

We read with interest the article of the American Geriatrics Society Expert Panel (AGSPE), describing patient-centered care for older adults with multiple chronic conditions (PMCs).1Within the population of PMCs, polypathological patients (PPs) stand out. This new notion has been introduced in the management of PMCs, arising from the needs of clinicians to approach the problems of PMC. PMCs are considered PPs when they have chronic diseases from two or more of eight predefined categories.2 These categories were established using criteria of established organ failure (independent of the primary disease), frequent chronic conditions with high mortality or the potential to become unstable, or frequent comorbidities when mental or functional impairment thresholds were definitively reached.2 The PPs constitute a homogenous population in terms of advanced age, complexity, high mortality, limited functionality, and vulnerability.2-4 These individuals probably reflect the same population that the AGSPE calls “older adults with multiple chronic conditions.” The homogeneity among these characteristics makes it clear that this new patient-centered notion of PP is solid and will make it possible to establish comprehensive intervention strategies designed for the main PP healthcare problems, as the expert panel suggests.1 This approach will become a cornerstone in the near future of most healthcare systems, because the effect of this population is not only qualitative, but quantitative as well. Hospital-based PP data from Andalusia (a region of southern Spain with 8,424,102 inhabitants) from 2000 to 2010 are detailed in Table 1 using the discharge information of the Minimum Basic Dataset from 33 Andalusian hospitals. Ten percent of the 6,286,704 discharges were PPs, with a continuous increase of this population over the study period.5 This increase was similar in medical and surgical Diagnosis-Related Groups (a system to classify hospital cases into one of originally 467 groups, to identify the “products” that a hospital provides), with a parallel increasing trend in discharges of older adults. Our data are concordant with those obtained in primary care settings 6 and reflect this emergent epidemiological–clinical paradigm to which clinicians, investigators, healthcare systems, and medical education institutions must attend. This is not an epidemic, but rather, at least in part, a social achievement as a result of previous generations' efforts, albeit an achievement that requires a deep adaptation of global healthcare systems. PP discharges, n (%) ≥3 categoriesaa ≥3,4, or 5 definitory categories of polypathological patients, this reflects the increasing complexity and disease's burden. , n (%) ≥4 categoriesaa ≥3,4, or 5 definitory categories of polypathological patients, this reflects the increasing complexity and disease's burden. , n (%) ≥5 categoriesaa ≥3,4, or 5 definitory categories of polypathological patients, this reflects the increasing complexity and disease's burden. , n (%) Conflict of Interest: The authors have no conflicts of interest to report. Author Contributions: All authors contributed substantially to the work. Sponsor's Role: No sponsor.

Reliability of a short questionnaire for the diagnosis of severe disability in polypathological patients attended in hospital setting

BackgroundA comprehensive evaluation of polypathological patients (PP) should always include a functional evaluation. For this purpose, a modified version of the Barthel Index (BI) is the most applied questionnaire, and it consists of a 10-variable scale. The aim of this study was to develop a screening and confirmation tool to diagnose high disability with the fewest number of dimensions of the BI as possible. MethodThis present cross-sectional observational multicentre study included PP attended in 36 Spanish hospitals that were divided into two geographical areas (Western and Eastern). The Western area was considered to be the derivation subgroup of PP, and the Eastern area was the validation subgroup. Complete disability for each item (value of 0) was assessed for the diagnosis of severe disability. Diagnostic validity indices (sensitivity, specificity, negative and positive predictive values [NPV and PPV, respectively], and negative and positive likelihood ratios [NLR and PLR, respectively]) were determined for the derivation subgroup. The dimensions with the best diagnostic validity indices were then used to evaluate the validation subgroup. ResultsThe analysis included 1521 PP, 753 PP from the Western area and 768 PP from the Eastern area. Needing complete help for bathing showed the highest NPV and lowest NLR in the derivation/validation subgroups (NPV 96.87/95.54, NLR 0.07/0.13). Being disabled for feeding alone showed high PPV and PLR values (PPV 97.97/95.65, PLR 109.25/49.62), as did disability for transfers (PPV 98.48/97.96, PLR 143.36/107.68). In addition, complete disability for feeding and transfers had the best PPV and PLR in both subgroups (PPV 100/100, PLR X/0). ConclusionsA two-dimension mini-Barthel Index may represent a reliable diagnostic test for severe disability in PP.

Anticoagulación en pacientes pluripatológicos con fibrilación auricular

Background and objectives To determine the use of oral anticoagulants in polypathological patients with atrial fibrillation and its influence on mortality and loss of functionality. Patients and methodsPatients with polypathological patient criteria and atrial fibrillation were included in an observational, prospective and multicenter study. Data on demographic, clinical, functional and sociofamilial characteristics, CHADS2 score, levels of hemoglobin, albumin and creatinine, use of oral anticoagulants and survival and functional status at one year were collected. ResultsFive hundred and thirty-two (32.6%) of 1,632 polypathological patients had atrial fibrillation. The stroke risk was high in 505 (94.9%), moderate in 24 (4.5%) and low in 3 (0.6%) patients. Oral anticoagulants were used in 61% of patients with CHADS2 score≥2 and in 37.5% with CHADS2 score=1. Oral anticoagulants were less used in older patients, with more functional and cognitive impairment. Heart failure was associated with more use of oral anticoagulants. There was no difference by the presence of hypertension, diabetes, anemia, renal insufficiency or stroke. In multivariate analysis the use of oral anticoagulants was independently associated with lower age, lower cognitive impairment, absence of hepatic disease and with higher stroke risk. The prescription of oral anticoagulants was independently associated with more survival at one year with no influence on functional status. ConclusionsOral anticoagulants are underused in polypathological patients with atrial fibrillation despite being associated with more survival.

Health care models for patients with multiple chronic conditions and the role of the hospital pharmacy/the hospital pharmacist

Managing care for patients with chronic conditions currently represents one of the greatest challenges to health care systems. As a subgroup of these patients, those with multiple chronic conditions are at greater risk for death or disability, and they consume more resources. They are characterized by the coexistence of two or more chronic illnesses lasting a year or longer which require ongoing medical attention and/or interfere with their daily activities. For these polypathological patients pharmaceutical care would be of special benefit, thus, their needs should be a priority objective for hospital pharmacy. To increase awareness of this type of patients and the characteristics of the principal approaches and health care models proposed to improve chronic disease management, as well as to emphasize the urgency for hospital pharmacists to join these models, and to present various activities that pharmacists might carry out as an integral part of these approaches. Numerous models exist internationally, including the Chronic Care Model and the Kaiser Permanente pyramid of risks. In our country a growing number of initiatives has culminated in the recent Seville Declaration. For the hospital pharmacy, caring for the chronically ill patient following a model that is multi-professional, cooperative, integral, and patient centered, is an enormous task. Pharmacy departments and the Spanish Society of Hospital Pharmacy should reorient their strategies for pharmaceutical care, training, and research. Of special interest are those activities designed to improve adherence, adequacy, and continuity in treatments, all the while emphasizing active patient participation.

Impact of Cognitive Impairment in a Multicentric Cohort of Polypathological Patients

Little is known about the prevalence and impact of cognitive impairment in polypathological patients (PPs). To assess the prevalence of cognitive impairment (CI) and delirium, their associated risk factors, and their impact on survival of a multicenter population of PPs. Prospective cohort study. Descriptive analysis of the prevalence, main clinical features of PPs with basal CI (by means of Short Portable Mental Status Questionnaire), and delirium (Confusion Assessment Method); and bivariate as well as multivariate assessment of the factors associated with both conditions. Survival analysis after 12 months follow-up by means of Kaplan–Meier curves, and multivariate analysis of mortality risk factors in PPs with CI, and those with delirium. CI was present in 39% [28% mild to moderate (3–7 errors), and 11% severe (≥ 8 errors)] of the 1434 PPs assessed [in the remaining 11% ( n = 198) delirium was detected]; only 26% of them had been previously diagnosed with dementia. One-year mortality was 46%/31.4% in those with/without CI [ p < 0.0001; relative risk (RR) = 1.8 (1.5–2.3)]. Mean survival was 305 ± 4/266 ± 5 days in those with/without CI ( p < 0.0001). One-year mortality was 54.5%/34.8% in PPs with/without delirium, [ p < 0.0001, RR = 2.25 (1.65–3)]. Mean survival after inclusion was 296 ± 4/241 ± 10 days in those with/without delirium ( P < 0.0001). Factors independently associated with mortality in PPs with CI were the presence of a concomitant active neoplasm [ p = 0.007; RR = 3 (1.3–6.7)], severe dyspnea ( p = 0.04; RR = 1.6 (1.02–2.6)], higher comorbidity load ( p = 0.003; RR = 1.2 (1.07–1.4)], and ≥ 4 hospital admissions in the previous 12 months [ p < 0.0001; RR = 5.2 (2.4–11.5)]. Factors associated with mortality in PPs with delirium were age ≥ 85 years [ p = 0.021, RR = 2.3 (1.14–4.6)], chronic liver disease ( p = 0.019, RR = 5.9 (1.3–25)], severe dyspnea [ p = 0.007; RR = 2.7 (1.3–5.4)], plasma creatinine levels > 2 mg/dL [ p = 0.003; RR = 7.8 (2–26)], and polypharmacy [ p = 0.0019; RR = 3.1 (1.2–8.1)]. CI, as well as delirium, is common in PPs. Both play a deleterious role in 12-month survival. A systematic cognitive assessment as well as prevention and early detection of delirium should be included in the clinical care of all PPs.

Functional Decline Over 1-year Follow-up in a Multicenter Cohort of Polypathological Patients: A New Approach to Functional Prognostication

Little is known about the fitness of the available tools in predicting functional decline of polypathological patients (PPs). Our objective was to assess accuracy of the Triage Risk Screening Tool (TRST), the Variable Indicative of Placement risk (VIP) and to develop a specific functional prognostic index adjusted to this population in a multicenter cohort of hospital-based PP. Prospective 12-month follow-up study of PPs from 36 hospitals. Functional decline was defined as loss of ≥20 points on Barthel’s index (BI). Accuracy of TRST/VIP was assessed by calibration/discrimination tests. Development of the new score was performed by dividing into a derivation cohort (constructing the index by logistic regression), and a validation cohort (in which calibration/discrimination of the index were tested). Nine hundred and fifty-eight patients from the 1632 included survived during follow-up. Basal/12-month BI was 85/70, respectively. Mean fall in BI score was 11.7 ± 24 points [353 (36.8%) fell by ≥20 points]. The activities for daily living that declined most frequently were toilet use, grooming, dressing and bathing. TRST/VIP fitted well but their discrimination power was poor (area under the curve = 0.49 and 0.46, respectively). A simplified PROFUNCTION index was derived containing seven items (≥85 years, neurological condition, osteoarticular disease, III–IV functional class of dyspnea, ≥4 polypathology categories, basal BI < 60, and social problems). Functional decline risk ranged from 21% to 24% in the lowest risk group (0 items) to 38–46% in the highest (4–7 items). Calibration as well as discrimination power (area under the curve = 0.56–0.59) of this simplified index were good. We developed and validated a new functional prognostic index specifically focused on these patients with better discrimination power than other tools available.

Prescriptions médicamenteuses en gériatrie : overuse (sur-utilisation), misuse (mauvaise utilisation), underuse (sous-utilisation). Analyse qualitative à partir des ordonnances de 200 patients entrant dans un service de court séjour gériatrique

PurposeIn the elderly three modalities of suboptimal drug prescriptions are known: overuse, misuse, underuse. Patients and methodsThis prospective observational study was conducted between September 2008 and March 2009. The prescriptions of 200 patients aged over 75years admitted in the acute care geriatric unit at the teaching hospital of Brest (France) have been qualitatively analyzed to assess the prevalence of the three types of suboptimal prescription. ResultsA strong prevalence of overuse (77% of the patients), underuse (64.5%) and at minor degree of misuse (47.5%) were evidenced. Overuse and misuse were more frequent in polypathogical and polymedicated patients living in nursing home. Underuse was more prevalent in polypathological patients living at home. No significant relation was found between suboptimal prescriptions, age, gender or cognitive status. ConclusionThis study demonstrates the strong prevalence of overuse, misuse and underuse prescriptions in hospitalized elderly patient and analyses the most frequently implicated drugs and the different factors predisposing to these suboptimal prescriptions. This way of analysis of prescriptions could be a pertinent method to improve drug prescription in the elderly.

Effects of renin–angiotensin blockers/inhibitors and statins on mortality and functional impairment in polypathological patients

BackgroundFrail and polypathological patients (PP) are often undertreated with evidence-based cardiovascular drugs, as their benefits are uncertain in this population. ObjectivesTo determine the effects of treatment with renin–angiotensin system blockers/inhibitors (ACEI/ARB), statins and/or beta-blockers on survival rates and functional decline in PP with evidence-based clinical indications for treatment with any of these drug families. MethodProspective observational multicentre cohort study with a 12-month follow-up period. We selected PP with any condition of the following: chronic heart failure, coronary heart disease, chronic renal disease, cerebrovascular disease, peripheral artery disease, diabetes mellitus with any visceral involvement, hypertension, and dyslipidaemia. Clinical, functional (Barthel index), socio-familial risk data and drug prescriptions were measured at baseline. Multivariate Cox proportional hazards and logistic regression models were used to identify variables independently associated with survival and functional decline. ResultsThe analysis included 1260 PP. The mean age was 79±9.5years. The mortality rate was 34.5%. Statin (aHR 0.671; P=0.001), beta-blocker plus statin (aHR 0.645; P=0.007), ACEI/ARB plus statin (aHR 0.680; P=0.002), or combined ACEI/ARB plus statin plus beta-blocker (aHR 0.541; P=0.000) prescriptions were associated with longer survival times. Additionally, PP whose Barthel index was ≥60 showed a lower risk of disability progression if treated with statins (aOR=0.476; P=0.000), or their combinations, mainly with ACEI/ARB plus beta-blockers (aOR 0.563; P=0.031). ConclusionsThe prescription of statins, alone or in combination with other drugs, may impact the survival and functional decline in polypathological patients. Further prospective blinded randomised assays are needed to confirm these observations.

Plan de formación continuada en una unidad de gestión clínica

Continuing Care Unit (UCA) focused the attention of frail patients, polypathological patients and palliative care. UCA attend patients at home, consulting, day unit, telephone consulting and in two hospitals of the health area. From2002 UCA began as a management unit, training has been a priority for development. Key elements include: providing education to the workplace, including key aspects of the most prevalent health care problems in daily work, directing training to all staff including organizational aspects of patient safety and the environment, improved working environment, development of new skills and knowledge supported by the evidence-based care for the development of different skills. The unit can be the ideal setting to undertake the reforms necessary conceptual training of professionals to improve the quality of care.

A multi-institutional, hospital-based assessment of clinical, functional, sociofamilial and health-care characteristics of polypathological patients (PP)

Little is known about the main features of the emergent population of PP. Our objective was to determine the clinical, care and social characteristics of a multi-institutional population of PP, by means of a cross-sectional study including a reference population of hospital-based PP from 36 hospitals. The main clinical, functional, mental and social features and their associated factors were assessed: 1632 PP (53% males, mean age 77.9±9.8 years) were included. An informal caregiver was required by 52% (78% of caregivers were close female relatives). The mean inclusion criteria (Cat): were 2.7±0.8 (49.5% presented ≥3 Cat). The most frequent inclusion Cat were heart (77.5%), lung (45.6%), neurological (38.2%), and kidney diseases (32.2%), whereas the mean of other comorbidities was 4.5±2.7 per PP. The mean Charlson comorbidity index (CCI) was 4; 47.6%, and 52.4% presented dyspnea ≥3 on the NYHA, and on the MRC, respectively; nearly 19% required home oxygen therapy, 19% had suffered >1 fall in previous year, and 11% suffered an active neoplasia. The mean hospital admissions in last 12/3 months, and chronically prescribed drugs were 2/1, and 8±3, respectively. More than 70% presented obesity, while 60% had hypoalbuminemia. The basal/inclusion Barthel index (BI) score was 69±31/58±34 (BI score<60 was present in 31.5%/44%, respectively); and the mean Pfeiffer score was 2.94±3.2 (43% answered with ≥3 errors). More than half of the subjects were at risk or already had established social problems. This emergent population is considerably homogeneous, highly complex, clinically vulnerable, functionally impaired, dependent on caregivers and socially fragile. They need to receive more attention in clinical research and more support in health interventions based on comprehensive attention and continuity of care.

Development of a new predictive model for polypathological patients. The PROFUND index

Background There is a concern about the accuracy of the available prognostic indexes when applying them to the emergent population of polypathological patients (PP). Methods To develop a 1-year mortality predictive index on PP, we developed a multicenter prospective cohort-study recruiting 1.632 PP after hospital discharge, outpatient clinics, or home hospitalization, from 33 hospitals. Potential risk factors were obtained in the 1.525 PP who completed follow-up. Each factor independently associated with mortality in the derivation cohort (757 PP from western hospitals) was assigned a weight, and risk scores were calculated by adding the points of each factor. Accuracy was assessed in the validation cohort (768 PP from eastern hospitals) by risk quartiles calibration, and discrimination power, by ROC curves. Finally, accuracy of the index was compared with that of the Charlson index. Results Mortality in the derivation/validation cohorts was 35%/39.5%, respectively. Nine independent mortality predictors were identified to create the index (age ≥ 85 years, 3points; No caregiver or caregiver other than spouse, 2points; active neoplasia, 6points; dementia, 3points; III–IV functional class on NYHA and/or MRC, 3points; delirium during last hospital admission, 3points; hemoglobinemia < 10 g/dl, 3points; Barthel index < 60 points, 4points; ≥ 4 hospital admissions in last 12 months, 3points). Mortality in the derivation/validation cohorts was 12.1%/14.6% for patients with 0–2points; 21.5%/31.5% for those with 3–6 points; 45%/50% for those with 7–10 points; and 68%/61.3% for those with ≥ 11points, respectively. Calibration was good in derivation/validation cohorts, and discrimination power by area under the curve was 0.77/0.7. Calibration of the Charlson index was good, but discrimination power was suboptimal (area under the curve, 0.59). Conclusions This prognostic index provides an accurate and transportable method of stratifying 1-year death risk in PP.

Interacciones medicamentosas en pacientes pluripatológicos

Objective To determine the prevalence of relevant drug-drug interactions (DDIs) and associated predictor factors in a sample of patients with multiple complex chronic diseases (polypathological patients) receiving multiple drug therapy. Our secondary objective was to determine the acceptance of a drug interaction reporting program with recommendations addressed to the prescribing physicians. Subjects and methods A cross-sectional study performed in three primary care centres assigned to a teaching hospital. All patients with 2 or more chronic diseases and treated simultaneously with 5 or more drugs were recruited in the study. DDIs were detected by using Drug-Reax System ® (Micromedex) program, the Drug Data Base (Bot) Spanish General Council of Official Colleges of Pharmacists or literature search when needed. Those DDIs which, according to the opinion of the pharmacist investigators, required any intervention were considered relevant. Acceptance of the reported DDI recommendations was evaluated by means of a survey addressed by primary care physicians ("acceptable," pertinent recommendation to modify treatment). Results A total of 283 polypathological polymedicated patients were included. Mean age was 74.5 years (range 43–100 years). Mean number of diseases per patient was 2.5 and prescriptions 9.7). Out of a total of 2748 drug prescriptions, 1053 DDIs in 250 patients (96.5%) were identified. Of these, 45% were filtered as relevant DDIs. The presence of ischemic heart disease, two or more hospital admissions and having received 7 or more prescriptions were associated with the presence of DDIs. 177 informs containing 473 recommendations about DDIs were sent to primary care physicians from our Pharmacy Department. 339 recommendations were answered by primary care physicians, and 84% were favourably accepted. Conclusions Almost every polypathological polymedicated patient is exposed to at least one DDI and about a 60% would require any intervention. Appropriate filtering and personalising recommendations in a collaborative way may represent an adequate manner to improve the risk-benefit ratio of the drug prescriptions.

Precisión de los criterios definitorios de pacientes con enfermedades médicas no neoplásicas en fase terminal. Proyecto PALIAR

It is a challenge to reliably identify the end-of-life trajectory in patients with advanced-stage chronic medical conditions. This makes advanced supportive care planning and transition from survival to comfort objectives more difficult in these emergent patient populations. To evaluate the sensitivity (Se), specificity (Sp), positive predictive values (PPV) and negative (NPV), and validity index (IV) of NHO criteria for terminal medical conditions, PPI and ECOG in patients with advanced heart, lung, liver, kidney and/or neurological diseases, and to build and validate an accurate index to determine this border-line. A multicentre prospective cohort study, with inclusion of patients with the predefined advanced medical diseases. Demographic, clinical, care, stratification and staging of disease(s), functional, analytical, NHO criteria, ECOG, PPS and PPI data collection; The end-point (death) will be assessed 180 days after inclusion. Analysis of Se, Sp, PPV, NPV, and IV of the NHO criteria, ECOG scale and PPI at 30, 60, 90, 120, 150 and 180 days. Derivation of PALIAR Index, after multivariate analysis and appropriate weighting of risk factors (beta of risk factor/lowest beta of the model), and validation in the validation cohort, and in the historical PROFUND cohort. The project is still ongoing, with 50 investigators from 33 hospitals throughout Spain, who have already included 1138 patients (92.5% during hospital admissions, 51.4% of them are male, with a mean age of 78.5 years). Mean inclusion chronic diseases were 1.4 per patient (44.5% of patients suffered chronic neurological diseases, 38.6% with heart failure, 34.2% with lung diseases, 12% with liver diseases, and 6.5% with renal diseases). Around 69% fulfilled the criteria of polypathological patients (mean Charlson index 3.4), and were prescribed around 8 drugs chronically. Mean Barthel index was 40 points, and 77% of them were dependent on a caregiver. Around 46% were ECOG-PS stage III or IV, and mean PPS score was 45 points. The availability of an accurate and powerful tool that could enable us to identify the end-of-life trajectory of these patients could allow us to establish specific intervention strategies for these populations. Therefore, and with these preliminary data, we believe that the PALIAR PROJECT will answer with rigour the questions and objectives of the study.

La discapacidad como barrera a la adherencia terapéutica en pacientes pluripatológicos: papel del cuidador principal

Objectives To determine which social and individual factors may predict adherence to medication in patients with more than two chronic symptomatic diseases (polypathological patients) under polypharmacy. Methods Cross-sectional observational study. In a primary care area assigned to our teaching hospital 265 patients with multiple chronic diseases and polypharmacy were recruited over a 6 month period. 84 patients with uncompleted data or died before finishing our study were excluded. An structured interview performed by a investigator different from responsible physicians was used. Drug adherence was assessed by a subjective method. Results Disability measured by Barthel index was was the main predictor of drug adherence. Patients without carer support and Barthel Index lower than 100 showed the poorer drug adherence. In the later group number of drugs also affected adherence. However, in patients with carer available, medication adherence was better, mostly in more disabled ones, and unaffected by other factors. Conclusions In patients with multiple chronic diseases, social support by a carer may allow disabled patients to overcome the barrier of disability leading to a better drug adherence, even than non-disabled ones. These findings may help to design future prospective studies on medication adherence performed in this peculiar frail population.

Perceived quality of healthcare in a multicenter, community-based population of polypathological patients

The objective was to determine perceived quality of care (PQC) in patients with multiple chronic conditions, whose care is structured in Andalusia (Spain) under polypathological patients (PP) care process, and identifying aspects for its improvement. The study was a community-based cross-sectional survey carried out in 4 primary care centers (which attended a total of 62,702 adults, of them, 662 were actively identified as PP). Finally, 461 PP and their caregivers were interviewed (69% of eligible population) including assessment of PQC following SERVQUAL model, clinical and demographical data. On a five-point Likert scale (from 1, ‘much worse than expected’; to 5, ‘much better’), PQC rated 3.68 ± 0.59 (±S.D.). Independent PQC predictors were: empathy for family physician, identifying nurses, presence of peripheral artery disease or diabetes mellitus with vascular complications, and not having functional limitations. In this population-based survey, PP attended at primary care have an acceptable PQC. Measures aimed to lessening functional deterioration, supporting dependent patients, and improving relationship between PP and their healthcare professionals could increase PQC.

Health network to improve elderly patients?? flow in emergency department

The French population has been growing older these past decades. The French Regional Health Organization System authorizes the creation of health networks in order to improve healthcare. We have developed since 2002 in our Tertiary Hospital Cochin, a health network inside Paris and its suburbs for the elderly to improve their flow from the emergency department. Our study, based on this organization, analyses the outcome of such a system. From January 2002 to December 2002, we conducted a monocentric retrospective study from the emergency department including all polypathological elderly patients (older than 75 years) admitted for a medical purpose. We classified them according to triage level at arrival, their duration of stay in the emergency department and in the tertiary hospital/geriatric network and their in-hospital mortality. Elderly patients represented 12% of our recruitment of an overall number of 42 700 patients in 2002. Six hundred and ninety-nine (24.2%) patients needed admission in a geriatric field; 42.8% were hospitalized in our tertiary hospital and 57.2% in the geriatric network. The mean age was 86.5+/-6 years in the two groups. The triage scale shows that most elderly people needed rapid care in the emergency department. Our mean duration of stay in the emergency department was 11 h 30 min. No significant difference was observed in the two groups for the in-hospital duration of stay. Mortality rate was 10.2% with a significant difference in the two groups. We observed a decreasing number of elderly persons' admission in our tertiary hospital, allowing a specific activity in the referred medical units. Our contract with the geriatric hospital in the network favoured elderly patients' flow from the emergency department. The geriatric network hospitals could refer back any patient to the emergency department for emergent events.

Facteurs de risque de la maladie thromboembolique veineuse chez des malades hospitalisés en médecine interne : une enquête cas–témoins sur 150 patients

Background. – Risk factors for the thrombo-embolic disease are not yet completely validated in medical setting. Indeed, there is a lack of scientific data concerning their prevalence and their thrombogenic weight. Methods. – We carried out a prospective case-control study in an internal medicine unit where general acute pathologies are recruited. We have included two patients without thrombosis for each patient admitted for a thrombo-embolic event. In all patients, at admission, clinical and biological risk factors for thromboembolism were systematically analysed in a physiopathological and chronological way. Results. – 450 patients were included during the 27 months period of the study. Among these patients, 150 were hospitalised for a deep venous thrombosis of the leg or/and a pulmonary embolism. Height risk factors have demonstrated their high thrombogenic potential: paralysis of the legs (OR = 13; 95% CI: 1.4 to 5.1), post-thrombotic syndromes (OR = 13; CI: 1.7 to 4.3), extrinsic compressions (OR = 8; CI: 1.3 to 5.4), pregnancy (OR = 6; CI: 1.2 to 6), malignancy occurred one year before (OR = 4; CI: 1.1 to 6.7), personal history of deep vein thrombosis (OR = 3; CI: 1.6 to 4.5), varicosity (OR = 2.5; CI: 1.2 to 6.1) and venous insufficiency (OR = 1.7; CI: 1 to 7.4). Four parameters, generally considered as risk factors, didn’t prove here their pathogenic power : the age over 60, obesity (BMI > 27), bedrest and the presence of an on-going malignancy. Conclusions. – Only risk factors with high thrombogenic power (as paralysis or extrinsic compression for example) could be identified by this kind of study performed in polypathological patients. In this particular population, usually recognised risk factors as age, obesity and bedrest are not determinant parameters for the thomboembolic risk evaluation.